ALERT BULLETIN AB 2018:9/3-4 3/13/ Boeing Commercial Airplane Company, FAA (AFS-400) INFO:

Transcription

1 ALERT BULLETIN AB 2018:9/3-4 3/13/ TO: INFO: Boeing Commercial Airplane Company, FAA (AFS-400) FAA (AVP-1, AVP-200, AFS-200, AFS-280, AFS-900, AAM-1, ANM-100, SEA- ACO, SEA-AEG, AQS-230), A4A, AFA, ALPA, AMFA, APFA, ASAP, ATSG, CAPA, IAM, IBT, ICAO, ICASS, IFALPA, NTSB, PAMA, SWAPA, TWU FROM: Becky L. Hooey, Director (Acting) NASA Aviation Safety Reporting System SUBJ: B767 Cabin Air Quality We recently received an ASRS report describing a safety concern that may involve your area of operational responsibility. We do not have sufficient details to assess either the factual accuracy or possible gravity of the report. It is our policy to relay the reported information to the appropriate authority for evaluation and any necessary follow-up. We feel you should be aware of the following: ASRS received multiple reports from the cockpit and cabin crew of a B767 describing a flight that diverted to an alternate after the cabin crew and a number of passengers began exhibiting physical symptoms related to poor cabin air quality. Symptoms included fatigue, dizziness and nausea. A cockpit crew member suggested the possibility of an ozone encounter, but the flight was not considered to be in an area of high ozone concentration. The ozone converter was reportedly a contributing factor in the event. To properly assess the usefulness of our alert message service, we would appreciate it if you would take the time to give us your feedback on the value of the information that we have provided. Please contact Dennis Doyle at (408) or at dennis.j.doyle@nasa.gov Aviation Safety Reporting System P.O. Box 189 Moffett Field, CA

2 ACN: Time Date: Local Time Of Day: Place Locale Reference.ATC Facility: ZZZZ.ARTCC State Reference: FO Altitude.MSL.Single Value: Environment Flight Conditions: VMC Aircraft 1 ATC / Advisory.Center: ZZZZ Make Model Name: B767 Undifferentiated or Other Model Component 1 Aircraft Component: Air Conditioning and Pressurization Pack Person 1 Function.Flight Crew: Captain Function.Flight Crew: Pilot Not Flying ASRS Report Number: Person 2 Function.Flight Crew: Pilot Flying Function.Flight Crew: First Officer ASRS Report Number: Person 3 Function.Flight Crew: First Officer Function.Flight Crew: Pilot Not Flying ASRS Report Number: Person 4 ASRS Report Number: Person 5 ASRS Report Number: Person 6 ASRS Report Number: Person 7 ASRS Report Number: Events Anomaly.Aircraft Equipment Problem: Critical Anomaly.Flight Deck / Cabin / Aircraft Event: Smoke / Fire / Fumes / Odor

3 Anomaly.Deviation - Procedural: Published Material / Policy Detector.Person: Flight Attendant Detector.Person: Flight Crew Result.General: Physical Injury / Incapacitation Result.General: Maintenance Action Result.Flight Crew: Landed in Emergency Condition Result.Flight Crew: Landed As Precaution Result.Flight Crew: Diverted Result.Flight Crew: Requested ATC Assistance / Clarification Result.Air Traffic Control: Provided Assistance Result.Air Traffic Control: Issued New Clearance Narrative 1 Cabin crew got lightheaded and dizzy, followed by pax same, spread from aft to whole cabin. No odor, fume detected. Multiple cabin crew and pax had symptoms. Decision to make a cautionary divert. Established at FL320, got call from aft cabin Flight Attendant that two of them were feeling lightheaded and dizzy, we agreed to cool down cabin and told them to keep us informed, Less than five minutes later we got another call that some passengers also were feeling lightheaded and dizzy, We called [maintenance] and Dispatch on conference call and all agreed that aircraft was nominal and we'd continue to monitor while thinking of a possible divert, less than fifteen minutes since initial call we also got a call from the purser that the entire cabin crew were also getting lightheaded and feeling dizzy. The decision to divert [was] made and we called the IRO (International Relief Officer) back to the cockpit from his break, ATC gave us expedited handling to ZZZZ where an overweight landing was made following the "Cabin Air Quality procedure" and "overweight Landing" procedure as well as normal approach and landing. F/O (First Officer) was directed to don oxygen mask as the flying pilot as part of normal ZZZZ procedure. Landed rolled to end of RWY using reverse and min braking to minimize heating of brakes. After exterior inspection by Fire and Rescue we taxied unassisted to [the stand] where we were met by EMT who took care of affected crew members and passengers, aircraft handed over to maintenance and flight crew went to the hotel. Narrative 2 I was PF (Pilot Flying) on this leg. Approximately two hours into the flight at FL320, we received a call from the aft flight attendants about one of the flight attendants feeling dizzy and nauseous. They asked us to cool the cabin down in the aft section, which we did. Shortly after that, we received another call from the aft cabin that the flight attendants were not getting "enough airflow" in the aft cabin. We further cooled the aft cabin to approximately 71 deg and explained we could not change the air flow rate. We asked them to ensure the gasper vents were open. Approximately five minutes later, we received another call from the aft cabin FAs stating that there were several passengers in the aft cabin who were also experiencing similar dizzy and nauseous symptoms. At this point, [the Captain] performed a sat phone patch to dispatch and [maintenance] to discuss the situation and evaluate potential divert options. We decided if we made the decision to divert, that ZZZZ would be our best option for the following reasons: 1. Longest runway since we would be 38,000 pounds above max landing weight. 2. Extensive crash rescue firefighter support in the event of hot brakes upon landing. 3. Adequate healthcare support and facilities to accommodate sick passengers. 4. Largest chance of re-booking passengers to their destination. 5. VMC weather conditions.

4 While [the Captain] was speaking with [maintenance] and dispatch, we received another call from the forward FAs stating they were experiencing similar symptoms to the aft passengers and FAs. At this point, we decided in concurrence with [maintenance] to divert to ZZZZ and alerted air-traffic control of our intentions. We asked the forward flight attendant to wake up [the First Officer] and have him return to the flight deck in preparation for diverting to ZZZZ. At no time did we experience or detect smoke or fumes, nor did we experience any of the symptoms of the passengers and flight attendants. The aircraft pressurization system and cabin altitude were normal. Prior to [the First Officer] arriving on the flight deck, we consulted the smoke, fire or fumes QRH, but concluded it did not match what we were experiencing. We also did not feel a MedLink patch was appropriate since we had multiple people who were sick with similar symptoms that seemed to be aircraft bleed system related and not a medical condition. Once [the IRO] arrived on the flight deck, [the Captain] briefed on the situation and we divided duties where I would fly and talk with ATC, while [the Captain] communicated with the company, station, FAs and passengers. Out of an abundance of caution, I put my oxygen mask on for the remainder of the flight. [The IRO] worked on the QRH checklist for overweight landing and fuel dumping. Dumping fuel would only eliminate 8,000 lbs of fuel and we would still be 30,000 overweight after dumping, so we decided against the procedure since we were descending over a populated area and thought it was more important to focus on properly flying the arrival and set up for approach/landing. After the arrival and approach were loaded into the FMC and [the Captain] and First Officer finished their tasks, we briefed the arrival, approach and overweight landing into ZZZZ. I briefed a flaps 25 landing since it would only be 1 knot faster ref than flaps 30, but would provide a much higher speed margin between target and max flap 25 speed. However, [the IRO] noticed the overweight landing QRH called for flaps 30, even though our target speed would be within 7 knots of max flaps 30 speed. We complied with the QRH and set flaps 30 for landing with auto brakes 1, planned to use max reverse until 80 kts and full runway length. A normal touchdown and long rollout was performed. We exited at the end of the runway where ARFF (Aircraft Rescue and Fire Fighting) contact was made and a visual inspection of the aircraft and brakes were performed by ARFF. Our highest brake temps indicated 2 on the BTMS (Brake Temperature Monitoring System). After an all clear was given by ARFF, we taxied to the gate. [The Captain] fielded questions from pax, FAs, station ops personnel, maintenance and ARFF. The pax and FAs who had symptoms inflight were evaluated and released by the EMT personnel. The flight attendants told us they were feeling better and their condition was improving. Upon reflection, it's possible we may have encountered an area of high Ozone concentration which could have led to some of the symptoms experienced by the pax and FAs and would explain the rapid recovery upon landing in ZZZZ. The trop was at 30,400 ft based on our [flight plan] and we were at FL320 for nearly 2hrs. While no ozone hazard area was depicted on our route map, the levels may have been sufficient to affect a portion of our pax and FAs. We did not think about running the Ozone Encounter QRH at the time, since we were not depicted to fly near any Ozone threat areas. Narrative 3 I was woken up during my crew rest by a flight attendant stating we are diverting because "we are not getting any air" and another flight attendant was using supplemental oxygen. I returned to the cockpit at and was brought up to speed on the situation and our need to divert to ZZZZ. We were about 35 minutes away from ZZZZ at that time and communications with dispatch and [maintenance] had already taken place before my return to the cockpit. The report from the flight attendant was that multiple passengers and flight attendants were feeling dizzy and lightheaded. They reported that the complaints started at the back of the plane and progressed forward. From that time until landing, I did what I could to assist the PF (Pilot Flying) and PM (Pilot Monitoring) by going over the Diversion Planning Guide in the QRH, the Cabin Air Quality

5 procedure in the FM (Flight Manual) and the Overweight Landing Checklist from the QRH. I also got frequent status updates from the flight attendants. Once the decision was made to divert, ATC was notified of our situation and the rest of the flight to ZZZZ was normal. We advised ZZZZ ATC of our medical emergency situation so we wouldn't have to hold getting into ZZZZ. All pressurization and other cockpit indications remained normal throughout the flight. I was in the crew rest seat for about 1 hour and never felt any adverse effect related to cabin air quality nor did I feel and adverse symptoms. After parking, we made the following Logbook entries: overweight landing, passenger Oxygen bottle used and Crew oxygen used. The ACARS timed-out/reset before we could enter possible fume/air quality complaint. ZZZZ maintenance met us and gave the Captain a 2 page questionnaire to fill out regarding the fume/air quality issue. Narrative 4 Approximately an hour into the flight crew members began to feel disoriented and lethargic. Two in particular were seriously affected, one needing oxygen and another vomited. Neither were able to continue with their duties. Other flight attendants and passengers began to complain of feeling ill. Many passengers looked as though they were suffering from hypoxia. They were unable to make simple decisions or to articulate what was the matter. I communicated with the Captain, keeping him informed of the situation as it evolved and insisted I believed there was something wrong with the air onboard. Thankfully he listened to me and made the decision to divert to ZZZZ. Once on the ground in ZZZZ flight attendants and affected passengers were treated by emergency personnel. We were told the next day by the mechanics there was a serious issue with the air onboard and that essentially we were breathing "poisoned air" it was recommended that we continue to monitor our health for at least the next 48 hours. Callback 4 The reporter stated that "A" Flight Attendant became very tired and observed others that were feeling tired also. A couple Flight Attendants required Oxygen and one passed out, all due to the air quality. The reporter stated that many passengers were also feeling ill. The reporter stated when they asked for more air in the cabin it only made matters worse. The reporter also stated their was no oder in the air, only lack of air. The reporter stated that the flight crew was very responsive to the Flight Attendants requests and diverted due to the air quality issue. The reporter also stated that the next day Maintenance informed them it may have been some oil in the air. The reporter stated that other air carriers have reported similar issues. Narrative 5 Normal condition up until about middle of the food and drink service. At one point during the service [a Flight Attendant] started to feel light headed and faint. She called the cockpit to ask the captain if everything is ok with the air flow. The answer was yes. All is good. Few minutes later [another Flight Attendant] started to feel ill and light headed. We sat her in an empty seat giving her oxygen and applying cold compress on her wrist and head. At this point I called the captain again to make sure all is well with the air. At this point every crew member including myself started to fill dizzy and light headed. The captain said all is checking out ok. We are flying at 45,000 feet and all is normal. as a crew we noticed the on a full flight in the middle of the day passengers seemed tired and their behavior was too calm and unusually laid back almost like an overnight flight. Couple of passengers also started to feel ill. [A Flight Attendant was] in the bathroom feeling sick. Few minutes later our purser called that we are heading to ZZZZ to check out the reason for the situation. We prepared the cabin to land in about 30 minutes. Shortly before touchdown there was an odor that we smelled. Smelled like antifreeze. The plane was brought to a hard stand. Emergency and medical personnel met flight. Also

6 customer service and inflight supervisors. Fireman checked out the plane. They suggested the ill passengers were taken off first to the waiting ambulance. Shortly after we deplaned passengers through doors 1l and 2l was done in a very orderly fashion. Then after everyone was off [the two ill Flight Attendants] where taken down to medical services on the ground. During this time [a supervisor] made all the arrangements for our transportation and hotel in no time. After the 2 flight attendants where checked out we were headed to the hotel. We all started to feel better after getting off the plane to the fresh air. The next day before our flight back we found out from the mechanics that the problem was the ozone converter. Narrative 6 While working in the left economy aisle, delivering beverages for the initial meal service, I noticed that I felt dizzy, nauseous, and light-headed and had trouble breathing. I saw that the majority of the passengers in the front section of coach were sleeping. I thought this was odd because it was a morning flight. I asked a lady passenger if she wanted ice with her drink and she said that she was so tired, she couldn't make that decision. I thought that was strange. I kept on serving drinks but I noticed that [another flight attendant], doing beverages on the other aisle, was like, five rows ahead of me. When I finished the drink service, I asked my crew in the galley if they felt odd. They didn't. But [the other flight attendant] said she felt dizzy too. I went up front and told [the A flight attendant] that I felt dizzy and she called the pilot who told her to open the air vents. She made an announcement that she knew the cabin was stuffy and advised passengers to open their vents. It was harder for me to catch my breath after that. I used to have asthma and I wondered if I was having an attack. At this point, the other crew members started feeling ill too. We knew something was wrong with the air in the cabin. [An aft flight attendant] went up front and talked to [the A flight attendant]. He told her that we all felt dizzy and light-headed. [One of the flight attendants] eyes were glassy, so she was put on oxygen. She talked to the Captain and he decided to divert to ZZZZ. As soon as we landed, I went into the restroom and threw up. After the left back door was open I went and inhaled the fresh air. I started to feel better after that. Narrative 7 Flight crew were complaining of difficulty breathing, nausea lightheaded and sluggish. We diverted to ZZZZ and upon landing the crew up by doors 1 left and right smelled anti-freeze type fumes. I was there at 1 center right. Prior to this we had served lunch to passengers and were communicating to cockpit thru the last hour or so of the flight in regards to the air quality and sick crew. One received oxygen. I think 2 of them vomited. After landing we were met by emergency personnel and ground staff. Medical attention to those who needed it. Were put up in hotel and worked back to [our original destination] the next day. Approx. 24 hours after the incident. We were told to monitor our health for the next 48 hours. Synopsis B767 flight crew reported that the quality of air in the cabin caused the cabin crew and some passengers to become light headed and ill. The ozone converter was reportedly a contributing factor in the event.